CT AND MRI FINDINGS OF RIGHT CARDIAC TUMOR REVEALING A DISSEMINATED LYMPHOMA: A CASE REPORT

1. CT AND MRI FINDINGS OF RIGHT CARDIAC TUMOR REVEALING A DISSEMINATED LYMPHOMA: A CASE REPORT H RIAHI, Y AROUS, M LANDOLSI, S KOUKI, H BOUJEMAA, N BEN ABDALLAH Radiology Department, Military Hospital of Tunis, Montfleury, Tunis, Tunisia E mail: younesmutu@yahoo.fr CR1

2. INTRODUCTION • Metastases to the heart and pericardium are much more common than primary cardiac tumors and are generally associated with a poor prognosis. • In autopsies at which a malignant neoplasm was diagnosed, cardiac metastases were found in 9.7%– 10.7% of case. • Tumors that are most likely to involve the heart and pericardium include cancers of the lung and breast, melanoma, and lymphoma

3. HISTORY • A30 year old woman presented with acute dyspnea and palpitations. • A transthoracic echocardiography was performed and showed a mobile echogenic mass. • Whole body CT and cardiac MRI were performed.

4. IMAGING FINDINGS • Hole body CT (64-section, General Electric) • Cardiac MR (Siemens Verio 3 Tesla): • Turbo spin-echo T1-weighted before and after contrast administration images • T2- weighted images (HASTE) • Steady state free precession images • Delayed enhancement images

5. ★ Contrastenhanced CT scan: lowattenuation mass of the right atrium and ventricle (★)and a pericardial effusion

6. Contrastenhanced CT scan: leftretroperitoneal mass () 

7. Contrastenhanced CT scan: bilateralovarian masses

8.  ★ Axial T1-weighted image before administration of gadolinium: isointense mass of the right cavities ()and a thickening of the interatrial septum(★) Axial T2-weighted image (HASTE): slightly hyperintensemass of the right cavities

9.  ★ Two-chamber and short-axis steady-state free precession images: mobile mass occupying almost the entire right cavity and a thickening of the right ventricular wall()and and the inferior wall of the left ventricle( ) ★

10. Axial, two chambers and short axis T1-weighted images after administration of gadolinium show heterogeneous enhancement of the right mass and the thickening of the interatrial septum and the inferior wall of the left ventricle.

11. Short-axis and two chambers delayed enhanced sequences: heterogeneous enhancement

12. A life-saving emergency operation was carried. The pathology report with immunostaining confirmed a diagnosis of B cell lymphoma. • A CT control showed a significantresponse to chemotherapyestimated to 80 %

13. DISCUSSION EPIDEMIOLOGIC FEATURES • Cardiac metastases are far more common than primary involvement, with an estimated ratio of 30:1. • In the presence of a malignant tumor, cardiac metastases are found in 9.7%–10.7% of cases. • The tumors that most frequently metastasize to the heart and pericardium are lung and breast cancers, melanomas, and lymphomas.

14. Involvement of the heart and pericardium is usually a late manifestation of lymphoma; the median time of onset is 20 months after initial diagnosis. • The tumors usually arise from the right side of the heart, often the right atrium, with frequent involvement of more than one chamber and are accompanied by a large pericardial effusion. • In approximately one third of patients with cardiac involvement, death will be directly attributable to the metastases as a result of pericardial tamponade, congestive cardiac failure, or coronary artery invasion

15. CLINICAL FEATURES • Although cardiac metastases from lymphoma are frequently found at autopsy, they are rarely diagnosed because most patients (90%) are asymptomatic • When present, the clinical signs and symptoms of cardiac metastases are nonspecific and include: • Fatigue, • Superior vena cava syndrome, • Congestive heart failure, • Cardiac arrhythmia, • Pericardial effusion, • Obstructed right ventricular inflow or outflow, • Transient ischemic attack

16. Arrhythmia remains the most common clinical sign of cardiac metastases, and its sudden appearance raises the possibility of cardiac metastatic involvement. • Tumor involvement and its consequences (cardiac tamponade, congestiveheartfailure, coronaryartery invasion, sinoatrial node invasion) are the cause of death in one-third of patients with cardiac metastases.

17. IMAGING FEATURES 1. CHEST RADIOGRAPHY: • cardiomegaly • pericardial effusion • signs of heart failure 2. ECHOCARDIOGRAPHY: • Cardiac mass in the right atrium or ventricle • pericardialeffusion

18. 3. CT: • lymphomas are hypoattenuating or isoattenuating relative to the myocardium • heterogeneous enhancement after intravenous administration of contrast material

19. 4. MR IMAGING: • poorly marginated and heterogeneous lesions • lobulated • isointense to slightly hypointense relative to cardiac muscle on T1-weighted MR images • isointenseto slightly hyperintense on T2-weighted images. • Gadoliniumadministrationproducesa heterogeneouspattern of enhancement.

20. CONCLUSION • Metastases to the heart occur late in the course of malignant disease. The patient typically has metastatic disease at other sites (usually pulmonary metastases are present). • Cardiac or pericardial locations are rarely the first sites of malignant disease. • Neoplasms with the highest frequency of cardiac and pericardial metastases include melanoma, leukemia, and lymphoma.

21. Involvement of the heart and pericardium is usually a late manifestation of lymphoma. • Our knowledge, it is the first case where a cardiac mass reveal a disseminated lymphoma. • The tumor usually arise from the right side of the heart, often the right atrium, and are accompanied by a large pericardial effusion.

22. MRI is presently the modality of choice to evaluate cardiac tumors. • High contrast resolution and multiplanar capability allow a specific diagnosis and optimal evaluation of myocardial infiltration, pericardial involvement and extracardiacextension. • Acquisition of postcontrast sequences enables better depiction of tumor vascularity and can be used to define tumor borders. • MRI has an important role in differentiating thrombi from cardiac tumors